Coding and guidelines changes for E/M services, Jan. 1

The American Medical Association (AMA) recently issued extensive changes to CPT^® evaluation and management (E/M) codes and guidelines. These changes build on the revisions to office/outpatient E/M codes in 2021 that emphasized medical decision making and sought to reduce documentation burden.

These E/M code and guideline changes affect inpatient and observation care services, consultations, emergency department services, nursing facility services, home or residence services, and prolonged services.

In addition, the Centers for Medicare & Medicaid Services (CMS) released prolonged services codes for services rendered for Medicare Advantage members. This impacts both payers and providers.

• Coding changes impact psychiatrists and qualified health practitioners who perform E/M services and all provider types who perform prolonged services.
• Key elements of the E/M code changes impacting Magellan providers include:
  • E/M guidelines related to hospital inpatient and observation care service codes, consultation codes, emergency department codes, nursing facility services codes, home or residence services codes.
    • Level of E/M services is based on the level of medical decision making (MDM) as defined for each service or the total time for the E/M service.
    • History and exam are no longer used to select the level of the code.
  • Revision/combining of hospital inpatient and observation care services E/M codes 99221-99233 and 99231-99239 and guidelines.
    • Hospital observation E/M codes were deleted.
    • Inpatient hospital services E/M codes were revised to include observation care services.
  • Revision/combining of domiciliary, rest home or custodial care E/M 99324-99338, 99334-99337 and home E/M codes 99341, 99342, 99344, 99345, 99347-99350 and guidelines.
    • Domiciliary, rest home or custodial E/M codes were deleted.
    • Home E/M codes were revised to include residence services.
  • Revision of consultations E/M codes 99242-99245, 99252-99255 and guidelines; deletion of lowest level consultation codes 99241 and 99251.
  • Revision of emergency department services E/M codes 99281-99285 and guidelines (time may not be used as a factor when selecting an ED visit).
  • Revision of prolonged services E/M code 99417 and guidelines. In 2023, 99417 can be reported with outpatient E/M codes 99205, 99215 and with outpatient consult codes 99245, and home or residence codes 99345 and 99350.
  • Addition of prolonged services E/M code 99418 and guidelines.
  • Addition of prolonged services HCPCS codes G0316, G0317, G0318 for Medicare Advantage members.

 

Magellan is amending provider agreements to include new add-on codes for prolonged services to commercial reimbursement schedules. 

Visit the AMA website for resource information, including videos and webinars.